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排尿障礙治療中心 版權所有 Pelvic Prolapse and Lower Urinary Tract Symptoms Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital.

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Presentation on theme: "排尿障礙治療中心 版權所有 Pelvic Prolapse and Lower Urinary Tract Symptoms Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital."— Presentation transcript:

1 排尿障礙治療中心 版權所有 Pelvic Prolapse and Lower Urinary Tract Symptoms Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2 排尿障礙治療中心 版權所有 Vaginal Prolapse Anterior vaginal prolapse – cystocele, urethral hypermobility, cystourethrocele Middle vaginal prolapse – apical prolapse, enterocele (bowel herniation), uterine prolpase, vault prolapse Posterior vaginal prolapse – rectocele (rectal herniation)

3 排尿障礙治療中心 版權所有 Anatomical classification of Pelvic prolapse

4 排尿障礙治療中心 版權所有 Prevalence of pelvic prolapse 11.1% of all women by age 80 years Comprise 16.3% of the indications for hysterectomy Patients often initially present to urologists with complaint of stress urinary incontinence

5 排尿障礙治療中心 版權所有 Vaginal support Vaginal vault – supported by cardinal and uterosacral ligaments Uterine support – broad ligaments attached to lateral pelvic wall Mid vagina – supported by lateral attachments to pubococcygeal muscles Distal vagina – embedded in connective tissue of perineal membrane and attached to urogenital diaphragm structures

6 排尿障礙治療中心 版權所有 The vaginal support

7 排尿障礙治療中心 版權所有

8 retroverted uterus: 1 st sign attenuation, stretching orBreakage??

9 排尿障礙治療中心 版權所有 u sp cx v r LP b ut 130 o

10 排尿障礙治療中心 版權所有

11 Coronal view Sagittal view

12 排尿障礙治療中心 版權所有 Pathophysiology of cystocele Weakened pubocervical fascia at the medial edge of the levator muscle Detachment of lateral vaginal wall from the pelvic side wall at the white line of arcus tendineus fascia

13 排尿障礙治療中心 版權所有 Pelvic organ support & prolapse

14 排尿障礙治療中心 版權所有

15 Classification of cystocele Anatomical grade: Gr I: Bladder descent toward introitus with straining Gr II Bladder to introitus with straining Gr III Bladder outside of introitus with straining Gr IV Bladder outside of introitus at rest VCUG grade: GrI: Just below inferior ramus Gr II: 2-5 cm below inferior ramus Gr III: Outside introitus and exterior

16 排尿障礙治療中心 版權所有 Cystocele

17 排尿障礙治療中心 版權所有 Cystocele Central defect: 5-15%, result from attenuation of the levator hiatus fascia Lateral defect: 70-80%, disruption of lateral attachments to vesicopelvic or pelvic side wall Combined central and lateral defects

18 排尿障礙治療中心 版權所有 Symptomatology of Anterior Vaginal prolapse Gr I and Gr 2 cystocele: asymptomatic or stress urinary incontinence Gr III and Gr IV cystocele: vaginal mass, lower abdominal fullness, frequency urgency, stress urinary incontinence, dysuria, leaning forward to void, residual urine sensation, frequent cystitis, dyspareunia, ureteral obstruction

19 排尿障礙治療中心 版權所有 Physical examination of vaginal prolapse Pelvic examination in supine and standing position Evaluate concomitant types of prolapse: rectocele and uterine prolapse Ask the patient to strain and relax with blade retraction of rectum or finger pushing the cervix upward Reduce cystocele to test stress incontinence

20 排尿障礙治療中心 版權所有 Differential diagnosis of cystocele Urethral diverticulum Ectopic ureterocele Cystourethrgraphy identified descent of bladder base and evaluate the urethrovesical angle MRI: diagnosis of cystocele with or without combination of enterocele or rectocele

21 排尿障礙治療中心 版權所有 Cystourethrography of Cystocele

22 排尿障礙治療中心 版權所有 Urodynamic study Multichannel pressure flow study:evaluate detrusor dysfunction, stress urinary incontinence, and voiding efficiency Provocative maneuvers: coughing, walking, jumping, straining to demonstrate SUI Detecting detrusor overactivity in patients with symptom of urge incontinence Residual urine volume determination

23 排尿障礙治療中心 版權所有 Uterine prolapse and cystocele causing bladder outlet obstruction

24 排尿障礙治療中心 版權所有 Reduction of prolapse relieves BOO in patient with SUI

25 排尿障礙治療中心 版權所有 Cystocele and Stress urinary incontinence High grade cystocele masks intrinsic sphincteric deficiency in 50-80% women Correction of cystocele without concomitant anti-incontinence surgery may unmask ISD and cause SUI Use of pessary test or vaginal pack for prolapse reduction and detecting genuine stress urinary incontinence

26 排尿障礙治療中心 版權所有 Cystourethroscopy and Lower urinary tract ultrasound Examination of bladder and urethral pathology, such as stone, tumor, stricture Bladder neck incompetence and intrinsic sphincter deficiency should be suspected Measurement of striated urethral sphincter component and bladder neck hypermobility by transrectal sonography of bladder & urethra

27 排尿障礙治療中心 版權所有 Female Urethral Incompetence Bladder neck incompetence Urethral incompetence

28 排尿障礙治療中心 版權所有 Urethral Ultrasound in ISD and Cystocele

29 排尿障礙治療中心 版權所有 Surgical procedure for cystocele Gr I: observation in asymptomatic women or bladder neck suspension when treating SUI High grade cystocele with SUI: anterior colporrhaphy with pubovaginal sling Correct uterine prolapse or rectocele concomitantly to prevent exacerbation of vaginal prolapse after colporrhaphy

30 排尿障礙治療中心 版權所有 Techniques of cystocele repair Raz 4 corner suspension Vaginal sling procedure Pubovaginal sling procedure with colporrhaphy Fascial patch repair to levator ani muscles and vaginal cuff or pubocervical fascia Burch colposuspension

31 排尿障礙治療中心 版權所有 Technique of Anterior colporrhaphy

32 排尿障礙治療中心 版權所有 Urodynamic point-of-view in cystocele repair Correct cystocele with adequate increased urethral resistance but not obstructing bladder outlet Patient with large cystocele may have detrusor underactivity and void by abdominal straining Accurate assessment of detrusor and urethral function during urodynamic study

33 排尿障礙治療中心 版權所有 Detrusor underactivity in Cystocele

34 排尿障礙治療中心 版權所有 Complications of cystocele repair Bladder injury during vaginal wall dissection Ureteral injury during placing plication sutures Urethral injury during dissection or suture passage Infection and fascia rejection Ureteral obstruction Stress urinary incontinence becomes prominent after cystocele repair

35 排尿障礙治療中心 版權所有 Postoperative Care Foley catheter and vaginal pack removed at day 1 or 2 Check residual urine after voiding till volume is less than 100ml Keep on antibiotics for 3 weeks to prevent synthetic material infection or abscess Laxatives and avoid abdominal straining

36 排尿障礙治療中心 版權所有 Postoperative urinary incontinence Intrinsic sphincteric deficiency is unmasked after cystocele correction De novo detrusor overactivity Urethral kinking due to improper placement of pubovaginal sling Videourodynamic study and transrectal sonography are indicated and a second sling can be applied at distal urethra for ISD Urethrolysis to relieve urethral obstruction

37 排尿障礙治療中心 版權所有 Transrectal sonography of ISD after repair of cystocele

38 排尿障礙治療中心 版權所有 Apical Vaginal prolapse (Enterocele) Peritoneal herniation at vaginal apex Sometimes difficult to differentiate from large cystocele or high rectocele Acquired enterocele (5-27%) after Burch culposuspension and leave a wide open cul-de-sac, or after hysterectomy and a weakened vaginal apex Can be prevented during pelvic surgery

39 排尿障礙治療中心 版權所有 Apical Enterocele

40 排尿障礙治療中心 版權所有 Symptomatology of Enterocele Mass at or beyond introitus Perineal pressure, vaginal mucosal erosion Mass will reduce spontaneously at supine

41 排尿障礙治療中心 版權所有 Physical examination of Enterocele Examined in supine and standing positions Ask patient to cough and strain, with finger or blade retraction of bladder or rectum Posterior vaginal wall length is normal in enterocele,but shortened in vault prolapse Check rectocele to find the presence of apical vaginal prolapse

42 排尿障礙治療中心 版權所有 Physical examination of Vaginal Cuff Prolapse

43 排尿障礙治療中心 版權所有 Treatment of Enterocele High peritonealization and approximation of uterosacral ligaments, obliteration of hernial sac and cul-de-sac When vaginal ulceration, vaginal surgery, or pelvic prolapse surgery is planned Abdominal approach or transvaginal approach is feasible

44 排尿障礙治療中心 版權所有 Transabdominal repair of Enterocele

45 排尿障礙治療中心 版權所有 Transvaginal Repair of Enterocele More direct and less morbid All component of vaginal prolapse should be repaired concomitantly Dyspareunia due to vaginal shortening should be addressed Approximation of levator ani at posterior vaginal wall can preserve vaginal depth

46 排尿障礙治療中心 版權所有 Transvaginal repair of Enterocele

47 排尿障礙治療中心 版權所有 Complication of Enterocele repair Small intestine injury – adhesion of small bowel after previous pelvic surgery or irradiation Rectal injury – careful vaginal wall dissection can prevent it Bladder perforation – in combined cystocele with enterocele Ureteral injury – during applying purse-string suture at herniac sac

48 排尿障礙治療中心 版權所有 Vaginal vault prolapse Due to vaginal apex weakness after previous hysterectomy Patients often have sensation of mass protruding from vagina Perineal pressure Dyspareunia Difficult urination and vaginal reduction to facilitate voiding

49 排尿障礙治療中心 版權所有 Pelvic examination of Vault Prolapse Posterior vaginal wall foreshortening Careful differential diagnosis from enterocele, surgical procedure is similar Nonsurgical procedure – a pessary Urodynamic study to investigate detrusor function and stress urinary incontinence

50 排尿障礙治療中心 版權所有 Pessary

51 排尿障礙治療中心 版權所有 vagina BL rectum

52 排尿障礙治療中心 版權所有 cx r bl USL

53 排尿障礙治療中心 版權所有 Uterosacral Ligament

54 排尿障礙治療中心 版權所有 AC Richardson: Breaks, not attenuation or stretching Site-specific defects Clin Obstet Gynecol 1993; J Pelvic Surg 1995



57 Surgical procedures for Vaginal Vault Prolapse Abdominal sacraocolpopexy – securing vaginal vault to sacrum using autologous, allogenic,or synthetic material to bridge the gap Transvaginal levator myorrhaphy – high approximation of levator uterosacral ligament complex at midline Sacrospinous ligament fixation Colpocleisis – closure of vagina in sexually inactive women

58 排尿障礙治療中心 版權所有 Transabdominal Sacrocolpopexy

59 排尿障礙治療中心 版權所有 Transvaginal Levator myorrhaphy

60 排尿障礙治療中心 版權所有 Sacrospinous fixation

61 排尿障礙治療中心 版權所有 Uterosacral ligament suspension

62 排尿障礙治療中心 版權所有 Uterosacral ligament suspension

63 排尿障礙治療中心 版權所有 Uterine prolapse Perineal pressure Dyspareunia Mass at introitus Urinary incontinence Difficult urination Constipation

64 排尿障礙治療中心 版權所有 Examination of uterine prolapse Evaluated in supine and standing position Voiding cystourethrography for cystocele and urethrovesical angle MRI to detect concomitant enterocele or rectocele Urodynamic study in supine (after reduction) and sitting position for voiding function and presence of ISD

65 排尿障礙治療中心 版權所有 Uterine prolapse

66 排尿障礙治療中心 版權所有 Surgical treatment Abdominal or vaginal hysterectomy with apical vaginal fixation to prevent postoperative vaginal vault prolapse Transvaginal levator myorrhaphy Repair other component of pelvic prolapse including cystocele, enterocele, rectocele by myorrhaphy or synthetic mesh or cadaveric fascia

67 排尿障礙治療中心 版權所有 Posterior vaginal wall prolapse Rectocele results from a weakened rectovaginal septum and perineal body Stool becoming stuck during defecation Chronic constipation Perineal pressure Backache Fecal incontinence

68 排尿障礙治療中心 版權所有 Rectocele

69 排尿障礙治療中心 版權所有 Grading of Rectocele Gr I (A) Protrusion with straining (B) Protrusion does not reach introitus Gr II Protrusion to introitus Gr III Protrusion outside introitus

70 排尿障礙治療中心 版權所有 Surgical repair of Rectocele To restore rectovaginal septum and perineal body Risk of rectal injury and dyspareunia secondary to vaginal tightening Repair the transverse perineal muscles by sutures at superficial and deep perineal muscles Not to close vagina too tightly

71 排尿障礙治療中心 版權所有 Technique of Rectocele repair

72 排尿障礙治療中心 版權所有

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